Reporting and Documenting Client Care

Summit Health Consulting Reporting and Documenting Client care There are a number of different environments in which you may work, such as a private residence, apartment complex or senior living facility. But no matter what environment, you are responsible for Reporting and possi-bly Documenting information about your clients on a daily basis, if needed. Depending on the nature of your Client s condition, you may even need to document hourly or more frequently. What is important to remember about Client care documentation ? Any written documentation regarding your Client acts as a permanent legal record of the Client s care You serve as the eyes and ears for the rest of the care team. Your observations help the team make the necessary changes in each Client s care plan and provides updates on the condition The information you report either by calling the office or by writing it down affects the care your cli-ents receive.

Rule # 2: Keep Your Documentation and/or Reporting Consistent Documentation and reporting is consistent when it remains true to: • The client’s care plan and directions given to you by your supervisor • Physician, nursing and other medical provider orders • The observations that you and your coworkers have made about the same client • Your workplace policies found in the …

Loading..

Tags:

  Care, Documentation

Information

Related search queries